BPO Medical Records Specialist

NTT
Manila
Workplace: OnsiteFull timeFunction: Healthcare (Clinical, Medical, Wellness)Experience: 1-3 yearsSkills: ["Communication","Analytic skills","Independent work","Judgement","Reading comprehension","Writing"]

Process and manage medical claim appeals within Medicaid and medical necessity review workflows. Research appeal cases, analyze applicable criteria, and prepare timely, accurate case reviews and communications for Medical Directors and stakeholders. Ensure compliance with state, federal, and NCQA standards, maintain appeal files, and support reconsideration decisions. Collaborate with providers, facilities, and internal teams to improve appeal consistency, efficiency, and prevention of repeat issues; may perform clinical reviews.

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FursaFursa
NTT
NTT
4 weeks ago

BPO Medical Records Specialist

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Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 5 hours agoStatus: Live
Reposted: similar role first listed 4 weeks ago

Job Summary

Process and manage medical claim appeals within Medicaid and medical necessity review workflows. Research appeal cases, analyze applicable criteria, and prepare timely, accurate case reviews and communications for Medical Directors and stakeholders. Ensure compliance with state, federal, and NCQA standards, maintain appeal files, and support reconsideration decisions. Collaborate with providers, facilities, and internal teams to improve appeal consistency, efficiency, and prevention of repeat issues; may perform clinical reviews.
Location: Manila
Workplace: Onsite
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Entry level

Key Responsibilities

  • •Research appeal requests and prepare case reviews for Medical Directors by analyzing the basis for appeals against applicable criteria.
  • •Ensure timely, accurate appeal processing and responses in accordance with state, federal, and NCQA standards.
  • •Review claim appeals for reconsideration and recommend approvals/denials or prepare medical review presentations.
  • •Communicate with providers, facilities, and other departments regarding appeal requests and required information.
  • •Maintain files on individual appeals by gathering, analyzing, and reporting member and provider appeal inputs and outcomes.

Key Requirements

  • •1-3 years of experience processing appeals or utilization management.
  • •Advanced experience (1 year) as team lead, trainer, SME, or QA.
  • •RN—Registered Nurse—state-required licensure and/or Compact State licensure.
  • •Knowledge of utilization management processes and Medicaid medical necessity review.
  • •Strong reading comprehension and writing skills with good communication and analytical judgment for non-routine appeals.
Experience:1-3 yearsUtilization managementMedicaid
Skills:CommunicationAnalytic skillsIndependent workJudgementReading comprehensionWriting
Licenses:RN - Registered Nurse licensure

Company Brief

NTT
Dimension Data, operating under NTT Ltd, provides managed IT services, cloud and data center solutions, networking, cybersecurity, and digital transformation services to enterprise customers worldwide.
Industry: Professional Services
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Established Company
Valuation: Public Company (Market Cap in USD)
Headquarters: London, United Kingdom
Founded: 1983
WebsiteLinkedIn